Summary A group of 10 paying passengers set out, in two rafts, on a river-rafting day trip down the Sulphur River near Grande Cache, Alberta. One raft was operated by a guide, the other by the trip leader, who was also the tour operator. There were five passengers per raft. At an abrupt descent in the Sulphur River known as the ledge, one of the rafts capsized, throwing its occupants into the water. One of the passengers, who apparently struck his head on an obstruction, was later found downstream, unconscious, floating face down in the water. Despite the continuous administration of cardiopulmonary resuscitation (CPR) from the time of his discovery onward, he was pronounced dead on arrival at the hospital in Grande Cache. Ce rapport est galement disponible en franais. Other Factual Information The Rafts The ZEBEC River Raft 450 S/B is an inflatable, self-bailing river raft manufactured in South Korea by Woosung I.B. Co. Ltd. It is 4.5 metres (m) long with an extreme breadth of 2.1 m, constructed of polymer material. The perimeter of the raft is entirely bounded by a flotation tube about 0.5 m in diameter, subdivided into four buoyancy compartments of approximately equal volume. Along each side are three equally spaced handles affixed to the exterior. The perimeter buoyancy tube angles upward at both bow and stern to increase freeboard (to about 0.7 m). The perimeter of the raft floor is penetrated by a series of grommet-reinforced holes. These provide the self-bailing capability of the raft. The central portion of the floor is constructed of a double thickness of material; when inflated, it serves as an additional buoyancy chamber. Three cylindrical buoyancy compartments (about 0.33 m in diameter), spaced equally athwartships across the midlength of the raft, are secured at their ends by laces to the inside of the perimeter buoyancy tubes. At the stern of the raft, resting on top of the perimeter buoyancy tube and secured to the raft by web straps, is a rectangular frame fabricated from 25-millimetre (mm) galvanized steel pipe to the specifications of the operator. Bolted to the aftermost part of this frame, on the centreline of the raft, is a plywood seat for the person controlling the raft. This frame also incorporates thole pins on both the port and starboard sides,[2] to which are clipped the steering oars used by the operator of the raft. The passengers are seated atop the athwartships buoyancy tubes; they wedge their feet under floor-mounted web straps or the athwartships buoyancy tubes in order to stabilize themselves within the raft while paddling. A lifeline is becketed around the uppermost surface of the perimeter buoyancy tube. For carrying the raft, there are moulded plastic handles, three per side, outboard on the port and starboard perimeter buoyancy tubes. Lines of approximately 5 m are fitted to the bow and stern on each raft. For identification purposes, the name of each raft is marked across the bow in 200 mm lettering. On 12 July 1999 both rafts were configured as described. Each of the two forward buoyancy tubes had a passenger port and starboard, and the third (aftermost) tube, a single passenger to port with some additional gear stowed to starboard. Included in the additional gear were materials for repairing the rafts, a hand-operated air pump and first-aid items. River Rafting Commercial river rafting is a form of adventure tourism operated by a loosely organized industry in Canada. Statistics on matters such as vessel activities, movements, client population and fleet size are not readily available. However, it is estimated that the industry caters to upwards of 140,000 passengers per year, and is growing. In western Canada, river rafting as a commercial enterprise dates from 1972, when expeditions were run on the Chilcoten and Fraser Rivers. The 1980s saw the emergence of oar- and paddle-powered rafting on small-volume, fast flowing rivers, where passengers could actively participate. The Tour Operation This whitewater rafting and tour business was established in 1990 by the current owner/operator, in Hinton, Alberta. For the most part, he is the sole employee and, as such, serves as trip leader.[3] Since 1994 the business had been based in Grande Cache, rafting on rivers in and around Willmore Wilderness Park. The operator estimates that he has made approximately 2,700 rafting trips, roughly 80 of them on the Sulphur River in 1999 prior to July 12. The operator reported having gained river-rafting experience, since 1979, in the Yukon Territory, British Columbia and Alberta. The guide, in charge of the second raft, had been employed by the operator on a part-time basis for four years and had 12 to 14 years' rafting experience. He had worked as a guide the four days prior to July 12. On July 11, commencing at 1100 mountain daylight time,[4] the guide and the trip leader had conducted a guided tour down the Sheep River. They each reported sleeping from approximately 2400 on July 11 until 0900 on July 12. This work/sleep pattern was reported to be similar to that followed by them on the four days prior to the occurrence. Promotional material that the business makes available includes the description Certified guides, 21 years experience. All needed safety equipment is provided. Wet suits P.F.D. Helmets and safety discussion before rafting will be given by guides. History of the Voyage Approximately six weeks before the occurrence, a representative of the passengers telephoned the trip leader to arrange the outing. Factoring in the number in the group, their lack of river-rafting experience together with their expectations, the Sulphur River trip was selected as the most appropriate among the alternatives available. The tour operator's brochure describes this trip as class 3. Various versions of the International Scale of River Difficulty describe class 3 as either Medium or Difficult (see Appendix A). The brochure does not mention specific hazards. At 1030 on July 12, the 10 passengers gathered at the operator's base of operations in Grande Cache. (Although the day was seasonably warm and sunny, with light winds, there had been significant snow accumulation at lower elevations due to late snows in the area. A result of this was that the rivers in the region were running at levels higher than normal.) Here they met the trip leader and guide, viewed the rafts FLIP and FLOP and the equipment to be used, and completed waiver forms. All of this was accomplished in advance of the wetsuits, personal flotation devices (PFDs) or helmets being distributed and fitted to the passengers. While the trip leader took final payment and arranged for supplies, the guide gave the passengers a demonstration of what they could expect while river rafting: the excitement, risks and dangers. The guide outlined the standard procedure during a run, safety precautions, the function and wearing of wetsuits, PFDs and helmets, as well as procedures to be followed should a person be thrown overboard: to not fight the current and thereby conserve energy. Before the group departed for the put-in point on the Sulphur River, three kilometres (km) away, a quantity of wetsuits and PFDs deemed sufficient for the group was stowed in the rafts. None of these articles was individually fitted. No sailing plan or passenger count was filed, either with search and rescue resources or with anyone else, prior to departure from Grande Cache at approximately 1115. A taxi and a pickup truck transported the passengers and rafts as close to the put-in point as the road permitted. Between the vehicle drop-off point and the river's edge, the group, together with their equipment, was required to descend a steep embankment approximately 75 m long, with an average incline of 40 degrees below the horizontal. It was the practice of the operator to send the rafts down a section of the embankment that, through use, had been worn free of vegetation; the raft would slide down the slope and come to rest in the undergrowth above the water's edge. The personnel would then follow a zigzag path to the bottom of the same slope. On this occasion, whilst the FLOP successfully negotiated the track down the slope, the FLIP upset part way along the track and tumbled to the bottom. At the bottom, the trip leader inspected the raft and discovered that the steering frame had been bent on the starboard side. Having noted this, the trip leader declared that the raft was serviceable and that the outing would proceed. By approximately 1140, all gear and personnel were assembled on the bank of the Sulphur River. At this time, the wetsuits and PFDs were broken out and distributed; it was then discovered that the equipment available was insufficient to equip each member of the group with properly fitting wetsuits and PFDs. The wetsuit normally worn by the trip leader was given to a passenger, and both the trip leader and guide went without wetsuits. PFDs were available but, while a range of sizes was provided, many of them were too small to fit as designed. When one passenger was unable to fasten the buckles of his PFD, a length of velcro was used to keep the vest snug against his body. At the water's edge, the trip leader gave the passengers a demonstration of what to expect and how to react. This included positioning, paddling instruction and commands. When a passenger asked about helmets he was told that for the section of the river on which they would be rafting, the wearing of helmets was an option rather than a requirement, and passengers were not encouraged to wear them. Consequently neither the trip leader, nor the guide, nor any of the passengers wore a helmet. Fitting of helmets was not demonstrated; the limited supply of available helmets remained in the FLIP. At approximately 1215, with five passengers in each raft, the group began its descent of the Sulphur River. By custom, the trip leader took the lead in the FLIP, while the guide followed in the FLOP. The river was quite gentle at this point. The two rafts had been on the river about five minutes when the trip leader elected to beach the FLIP for maintenance, which included topping up the buoyancy chambers with additional air. After paddling, it had become apparent that the bent steering frame compromised the manoeuvrability of the FLIP. The passengers were utilized to straighten the frame by pulling on each side of it. After several attempts, the trip leader declared that the frame was sufficiently straightened and that the trip could continue. At approximately 1225, passage was resumed. All passengers had paddles. However, the drill was for them to paddle only on instruction from the trip leader, who controlled the raft by means of oars. During the next half hour, the trip leader several times brought the raft close to dangers along the river: boulders, logs and the sometimes-bluff banks at the river's edge. Some passengers felt that the trip leader waited longer than necessary before veering the raft clear of these hazards. One passenger's concern was that people might strike their heads against overhanging hazards. In response to these concerns, the trip leader subsequently maintained a greater distance from these hazards. Approximately 5 km from the put-in point is an overfall, or drop,[5] approximately 90 centimetres high, referred to as the ledge. With minor variations, it continues unbroken across the river from bank to bank (see photograph 2). The rafts are designed with increased freeboard at each end, and the generally accepted approach for turbulent waters, such as the ledge, is head-on. In the minutes before reaching the ledge, the trip leader spoke to the passengers about the river and about his experiences. While he was engaged in conversation with one of the passengers, the raft approached the ledge. The trip leader reportedly instructed all of his passengers to paddle; however, his instruction was not universally understood--passengers on the port side of the raft paddling only for a moment before stopping. The raft was swept broadside over the ledge, whereupon it capsized. The estimated time was 1245. Only one passenger can recall hearing a warning and paddling instruction in the moments prior to the accident. The FLIP went over the ledge with its starboard side leading; it rolled to starboard and then to port, and then capsized. All occupants were spilled out of the raft and into the water. Of the six occupants, two surfaced beneath the upturned raft while the remainder found themselves adjacent to it. The two passengers beneath the raft, by their own efforts, swam clear; one upstream, the other downstream. The raft was undamaged. Injuries to Persons For moments after capsizing, the FLIP remained stationary, caught in the reversal at the base of the ledge.[6] Once everyone was clear from beneath the capsized raft, the six occupants were distributed about the FLIP. Three of the passengers were downstream of the raft. One of these three passengers lost his glasses and, with his vision limited, made his way to the left bank. The passenger furthest from the raft was seen to be floating downstream with the current; he was face up and wearing his PFD but showed no movement. The trip leader reported that at first he had managed to grasp this person's PFD to try to assist him. At that time he noticed signs of blood at the base of the victim's skull. The trip leader reported that he then lost his grip and the victim floated downstream with the current. The remaining downstream passenger also lost his grip on the raft and was carried with the current away from the ledge. The trip leader and the two passengers remaining with the overturned raft were able to extract it from the reversal and, clinging to it, proceed downstream an estimated 300 m, at which point they were able to stop the raft and right it. Despite wearing PFDs and wetsuits, the passengers reported that, upon being immersed, they noticed that the water was cold. The temperature of the water was below 10 degrees Celsius. When the trip leader observed the blood on the victim's head he concluded that the victim was unable to assist himself but he did not share this information with the others in the water. The trip leader reassured his two passengers that the most difficult part of the river was now behind them. After righting the raft, the trip leader and the two passengers with him continued downstream in search of the two passengers last seen floating in the river. Shortly afterward, one of the two was sighted running downstream through the water along the left bank. The raft was manoeuvred close enough for this person to be pulled aboard. As the raft travelled downstream, the people in the raft recovered paddles that had been lost when the raft upset. The buckled PFD worn by the victim was recovered later that day by another rafting party which included both the trip leader and guide. Minutes later, the victim was seen floating face down in the water. As the raft passed by, one passenger jumped from the raft and was able to pull the victim to shore. The raft was manoeuvred to shore a short distance further downstream. When the passengers and trip leader ran upstream to the victim, they found that their fellow passenger had begun CPR. The location was approximately 2.5 km downstream of the ledge, and the time, approximately 1300. While awaiting the FLOP, the survivors administered CPR to the victim, who was unconscious and bleeding from a wound on the back of his head. The FLOP had been far enough astern of the FLIP that her occupants were unaware of the capsizing, she negotiated the ledge without mishap. The occupants were alerted to trouble upon seeing the passenger from the FLIP who had waded ashore after losing his glasses. The FLOP was carried about 200 m downstream from the ledge before they were able to put it ashore to retrieve that passenger. Due to the rough terrain, it took the guide an estimated 15 minutes before he was able to return to the raft with the passenger and proceed to the aid of the FLIP. As neither raft carried any communication equipment, communication between the rafts (or from a raft to shore) was not possible. At approximately 1320, the FLOP came into view of the trip leader and passengers of the FLIP who, on the bank of the river, continued to administer CPR to the victim. As the FLOP passed by, the guide informed the trip leader that he had picked up the passenger from the shore. All personnel were now accounted for. The guide, in turn, was made aware of the gravity of the situation. It was agreed that they would utilize an alternate take-out 3 km downstream, the closest road access, and seek assistance; the FLIP would follow. The trip leader, with the victim and three remaining passengers, borne by the FLIP, joined the FLOP and her crew at the alternate take-out at approximately 1345. In the meantime, the guide had searched for a method of transporting the victim to hospital or a means of alerting assistance. A vehicle and driver were located. The trip leader travelled in the vehicle directly to the Royal Canadian Mounted Police (RCMP) station in Grande Cache, arriving there at 1410. The Grande Cache RCMP detachment and other emergency services are located in the same building. An ambulance and two RCMP vehicles were dispatched without delay. One of the RCMP units, a 4x4 GMC Suburban, was used to transport the victim up the rough, steep grade between the beach and gravel road leading to town for transfer to the waiting ambulance. The victim was pronounced dead on arrival at the Grande Cache hospital. A subsequent autopsy determined drowning to be the cause of death. Regulations and Standards Federal The Small Vessel Regulations do not require river rafts such as the FLIP to be registered or licensed, although certain provisions may apply. In 1978, pursuant to the Canada Shipping Act, Transport Canada established the Boating Restriction Regulations. The River Rafting Standards(TP8643) were promulgated in 1987. These standards set out minimum requirements for the safe operation of commercial river raft operations. The standards address, inter alia, construction, equipment, capacity, safety equipment and qualifications of trip leaders and guides. The Boating Restriction Regulations require the provinces to list the waters to which certain provisions will apply. Six provinces, including Alberta, have listed their waters for particular provisions. The River Rafting Standards are applicable to the waters listed in Schedule VI.I of the Boating Restriction Regulations (white waters for which a permit is required to operate a commercial river raft). The Province of British Columbia is the only province which has chosen to list its waters under Schedule VI.I. The River Rafting Standards do not apply in Alberta and therefore do not apply to this operation. The Canadian Rivers Council The Canadian Rivers Council (CRC), with twenty member outfitters, represents rafting operations primarily in Ontario and Quebec. Over time the Council has developed its own, voluntary safety regulations and a system to administer and regulate its membership. British Columbia In British Columbia, during a seven-week period in 1987, four separate river-rafting accidents resulted in 12 fatalities. In 1988 the Government of British Columbia produced the Report of the Advisory Committee on Commercial River Rafting in British Columbia. The Report explains that, when the River Rafting Standards were adopted, the industry, through its voluntary membership in the River Outfitters Association of British Columbia (R.O.A.B.C.), attempted to ensure that its membership conformed to the guidelines. The Report states: However, the R.O.A.B.C. was unable to police the industry because (1) they lacked a method of enforcement, (2) the industry was small and highly competitive, so negative judgements about an operation are seen as an aggressive business tactic, and (3) only a portion of industry was represented in the voluntary membership because of the wide geographical location of members and the resultant difficulty in attending meetings. Had the industry been able to police itself, government enforcement would not be required. In response, the Government of British Columbia developed the Commercial River Rafting Safety Act and Regulations, administered through its Ministry of Environment, Lands and Parks by the Registrar of Commercial River Rafting. Alberta Alberta does not have regulations specific to whitewater rafting. There are, however, two self-regulating associations; the Jasper National Park Professional River Outfitters Association (JNPPROA), which is for outfitters operating within Jasper National Park, and the Professional River Outfitters Association of Alberta (PROAOA). Both associations, within their respective mandates, promote safe river rafting. The percentage of operators within these associations is low; however, PROAOA is making efforts to increase its membership. Each organization has developed standards similar to those of the CRC. The owner of FLIP was not a member of the CRC or of either Alberta association and did not self-regulate to any of the standards set by and available from these organizations.